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1) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The facility failed to protect hazardous areas with One hour fire rated construction (with ¾ hour fire-rated doors) and with self-closing doors. Findings include:

a) The facility was constructed with a morgue, however the facility changed the room use into a store room for trash. The room was not provided with a closure or submitted for re-purposing room use.

1) Based on observation, interview with staff, the facility failed to provide maintenance and testing program for the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The facility failed to have a fire alarm test for the old hospital housing the Clinic and lab.

b) The facility corrected yellow tag deficiencies, however the facility failed to get a re-acceptance test in accordance with NFPA 72 1999 edition 7-1.6.2.1 from the vendor who repaired the deficiencies.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover; the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) The facility was not logging humidity in Operating Rooms and in Central Sterile.

b) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations. Operating Room Staff had not been thoroughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10.

c) Staff was unfamiliar with all equipment in the room and function of utilities. Staff could not identify operational devices such as smoke evacuation systems, staff failed to adopted and provide upon request manometer reading that depict life of the HEPA Filters, and staff failed to in-service staff regarding operational means and method of electrical service. Operating Room staff was unfamiliar with normal and emergency power option in the event of the transfer switch failure, operating room staff was unfamiliar with location of circuit panels.

1) Based on observation and interview with staff, the facility failed to ensure that the condition of the physical plant and overall Critical Access Hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer ' s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the CAH ' S QA plan. The Governing Body was not informed that the equipment was broken. See Interpretive Guidelines §485.623(b)(1) Findings include:

a) The water softeners were not working.

2) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

a) The scope cleaning room hand sink was removed.

b) Cleaning room failed to provide the flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination. The Medivator was positioned which allowed for droplet contamination to transfer from dirty to clean, there was no room to change dirty aprons; aprons were not provided in the room. The door was propped open.

c) At least two (2) utility sinks remote from each other.
d) Ventilation system. Negative pressure shall be maintained and at least ten (10) air changes per hour shall be maintained. A hood shall be provided over the work counter. The facility did not have documentation or commissioning report that documented air exchanges.
3) Based on observation and interview with staff, the facility failed to ensure that all locations of the CAH, including all satellites, all provider-based activities are incorporated into the CAH ' S QA program and be in compliance with the QA requirements. Interpretive Guidelines §485.623

a) the facility failed to ensure that routine and preventive maintenance and testing activities were performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer ' s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities was no incorporated into the CAH ' S QA plan for the three off site facilities and the old hospital. The fire alarm and fire suppression system was out of date for annual inspection at the old hospital, housing Lab and Clinic. Engineering stated that they did not have a copy of the fire alarm and fire suppression report for the other three facilities located at 3739 Legacy in Weatherford, Oklahoma.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings:

a) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients in accordance with NFPA 99 1999 edition chapter 7.6.5. Personnel involved in the use of energy-delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, shall receive periodic training in fire suppression. The facility used and stocked one time use battery cautery tool located in the operating room, staff could not provide documentation for fire suppression and prevention for this device or any other device used in the building, staff had not made a list of equipment that requires staff to take precautions in application or periodic training.

b) The facility did not have a Impedance Testing program for patient care areas in accordance with NFPA 99 1999 edition chapter 3-3.3.2.4

c) The facility failed to test receptacles in accordance with 3-3.3.3. Receptacles shall be confirmed with visual, continuity of ground, correct polarity, and retention.

d) The facility did not have a record keeping system for impedance testing or receptacle testing in accordance with 3-3.4.3.1. At a minimum, records shall be kept with date, location, and test results.

e) The governing body failed to document or ensure that the services performed under a contract were provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor was reviewed and documentation was not available. The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

1) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The facility failed to protect hazardous areas with One hour fire rated construction (with ¾ hour fire-rated doors) and with self-closing doors. Findings include:

a) The facility was constructed with a morgue, however the facility changed the room use into a store room for trash. The room was not provided with a closure or submitted for re-purposing room use.

1) Based on observation, interview with staff, the facility failed to provide maintenance and testing program for the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The facility failed to have a fire alarm test for the old hospital housing the Clinic and lab.

b) The facility corrected yellow tag deficiencies, however the facility failed to get a re-acceptance test in accordance with NFPA 72 1999 edition 7-1.6.2.1 from the vendor who repaired the deficiencies.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover; the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) The facility was not logging humidity in Operating Rooms and in Central Sterile.

b) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations. Operating Room Staff had not been thoroughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10.

c) Staff was unfamiliar with all equipment in the room and function of utilities. Staff could not identify operational devices such as smoke evacuation systems, staff failed to adopted and provide upon request manometer reading that depict life of the HEPA Filters, and staff failed to in-service staff regarding operational means and method of electrical service. Operating Room staff was unfamiliar with normal and emergency power option in the event of the transfer switch failure, operating room staff was unfamiliar with location of circuit panels.

1) Based on observation and interview with staff, the facility failed to ensure that the condition of the physical plant and overall Critical Access Hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer ' s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the CAH ' S QA plan. The Governing Body was not informed that the equipment was broken. See Interpretive Guidelines §485.623(b)(1) Findings include:

a) The water softeners were not working.

2) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

a) The scope cleaning room hand sink was removed.

b) Cleaning room failed to provide the flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination. The Medivator was positioned which allowed for droplet contamination to transfer from dirty to clean, there was no room to change dirty aprons; aprons were not provided in the room. The door was propped open.

c) At least two (2) utility sinks remote from each other.
d) Ventilation system. Negative pressure shall be maintained and at least ten (10) air changes per hour shall be maintained. A hood shall be provided over the work counter. The facility did not have documentation or commissioning report that documented air exchanges.
3) Based on observation and interview with staff, the facility failed to ensure that all locations of the CAH, including all satellites, all provider-based activities are incorporated into the CAH ' S QA program and be in compliance with the QA requirements. Interpretive Guidelines §485.623

a) the facility failed to ensure that routine and preventive maintenance and testing activities were performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer ' s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities was no incorporated into the CAH ' S QA plan for the three off site facilities and the old hospital. The fire alarm and fire suppression system was out of date for annual inspection at the old hospital, housing Lab and Clinic. Engineering stated that they did not have a copy of the fire alarm and fire suppression report for the other three facilities located at 3739 Legacy in Weatherford, Oklahoma.

1) Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings:

a) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients in accordance with NFPA 99 1999 edition chapter 7.6.5. Personnel involved in the use of energy-delivering devices, including, but not limited to, electrosurgical units surgical lasers, electrocauterizers, and fiberoptics, shall receive periodic training in fire suppression. The facility used and stocked one time use battery cautery tool located in the operating room, staff could not provide documentation for fire suppression and prevention for this device or any other device used in the building, staff had not made a list of equipment that requires staff to take precautions in application or periodic training.

b) The facility did not have a Impedance Testing program for patient care areas in accordance with NFPA 99 1999 edition chapter 3-3.3.2.4

c) The facility failed to test receptacles in accordance with 3-3.3.3. Receptacles shall be confirmed with visual, continuity of ground, correct polarity, and retention.

d) The facility did not have a record keeping system for impedance testing or receptacle testing in accordance with 3-3.4.3.1. At a minimum, records shall be kept with date, location, and test results.

e) The governing body failed to document or ensure that the services performed under a contract were provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor was reviewed and documentation was not available. The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.